Drug Interactions between Lexapro and topiramate

Alcohol can increase the nervous system side effects of escitalopram such as dizziness, drowsiness, and difficulty concentrating. Some people may also experience impairment in thinking and judgment. You should avoid or limit the use of alcohol while being treated with escitalopram. Do not use more than the recommended dose of escitalopram, and avoid activities requiring mental alertness such as driving or operating hazardous machinery until you know how the medication affects you. Talk to your doctor or pharmacist if you have any questions or concerns.

Adult and pediatric patients with depression and other psychiatric disorders may experience worsening of their symptoms and may have the emergence of suicidal thoughts and behavior. Patients should be monitored appropriately and observed closely for worsening of their symptoms, suicidality or changes in their behavior, especially during the first few months of treatment, and at times of dose changes. Families and caregivers should be advised of the need for close observation and communication with the treating physician. Discontinuing the medication should be considered if symptoms are persistently worse, or abrupt in onset. It may be prudent to refrain from dispensing large quantities of medication to these patients.

Oligohidrosis (decreased sweating) and hyperthermia have been reported in association with the use of some carbonic anhydrase inhibitor anticonvulsants such as topiramate and zonisamide. Most of the reports have been in children. Caution and close monitoring of body temperature is advised when prescribing these drugs, especially in patients with a fever, in hot weather, or if combined with other drugs that predispose to heat related disorders. Zonisamide is not approved for use in pediatric patients in the U.S.

Adult and pediatric patients with depression and other psychiatric disorders may experience worsening of their symptoms and may have the emergence of suicidal thoughts and behavior. Patients should be monitored appropriately and observed closely for worsening of their symptoms, suicidality or changes in their behavior, especially during the first few months of treatment, and at times of dose changes. Families and caregivers should be advised of the need for close observation and communication with the treating physician. Discontinuing the medication should be considered if symptoms are persistently worse, or abrupt in onset. It may be prudent to refrain from dispensing large quantities of medication to these patients.

Reduced plasma bicarbonate levels and, in some instances, elevated plasma chloride levels may result in metabolic acidosis during long-term therapy with carbonic anhydrase inhibitors. Therapy with carbonic anhydrase inhibitors should be administered cautiously in patients with metabolic or hyperchloremic acidosis or with conditions that predispose to acidosis (renal disease, severe respiratory disorders, diarrhea). The measurement of baseline and periodic serum bicarbonate is recommended. If metabolic acidosis develops (it may be corrected by administration of sodium bicarbonate), and persists, a dose reduction or treatment discontinuation should be considered.

Selective serotonin reuptake inhibitors (SSRIs), like other antidepressants, may occasionally cause or activate mania or hypomania. The reported incidence ranged from 0.1% to 2% in premarketing testing of several SSRIs. Patients with bipolar disorder are generally more likely to experience mania from antidepressants. Therapy with SSRIs should be administered cautiously in patients with a history of mania or bipolar disorder. Prior to initiating treatment, it is recommended to adequately screen patients for bipolar disorder, including a family history of suicide, bipolar disorder, and depression.

The use of selective serotonin reuptake inhibitors (SSRIs) has been associated with altered platelet function. Petechiae, purpura, ecchymosis, increased bleeding times, epistaxis and gastrointestinal hemorrhage have been reported. Therapy with SSRIs should be administered cautiously in patients with severe active bleeding or a hemorrhagic diathesis.

Reduced plasma bicarbonate levels and, in some instances, elevated plasma chloride levels may result in metabolic acidosis during long-term therapy with carbonic anhydrase inhibitors. Therapy with carbonic anhydrase inhibitors should be administered cautiously in patients with metabolic or hyperchloremic acidosis or with conditions that predispose to acidosis (renal disease, severe respiratory disorders, diarrhea). The measurement of baseline and periodic serum bicarbonate is recommended. If metabolic acidosis develops (it may be corrected by administration of sodium bicarbonate), and persists, a dose reduction or treatment discontinuation should be considered.

The use of selective serotonin reuptake inhibitors (SSRIs) has been associated with altered platelet function. Petechiae, purpura, ecchymosis, increased bleeding times, epistaxis and gastrointestinal hemorrhage have been reported. Therapy with SSRIs should be administered cautiously in patients with severe active bleeding or a hemorrhagic diathesis.

The use of topiramate increases the risk of kidney stones. The reported incidence was 1.5% during premarketing use, which is about 2 to 4 times that expected in a similar, untreated population. Topiramate is a carbonic anhydrase inhibitor and may promote stone formation by reducing urinary citrate excretion and increasing urinary pH. Therapy with topiramate should be administered cautiously with adequate hydration in patients, especially those with predisposing factors (e.g., history of nephrolithiasis), to minimize the risk of kidney stone formation. The concomitant use of topiramate with any other drug producing metabolic acidosis, or potentially in patients on a ketogenic diet, may create a physiological environment that increases the risk of kidney stone formation and should be avoided. Patients who are dehydrated may be at increased risk for the development of nephrolithiasis and should be encouraged to consume additional amounts of liquid during topiramate therapy.

The use of selective serotonin reuptake inhibitors (SSRIs) has rarely been associated with hyponatremia, sometimes secondary to development of the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). These events have generally been reversible following discontinuation of SSRI therapy and/or medical intervention. SSRI-related hyponatremia may be more common in elderly female patients and those who are volume-depleted or receiving concomitant diuretic therapy. Caution may be warranted when SSRI therapy is administered in these patients and patients with preexisting hyponatremia or SIADH. Serum electrolytes, especially sodium as well as BUN and plasma creatinine, should be monitored regularly.

Selective serotonin reuptake inhibitors (SSRIs), like other antidepressants, may occasionally cause or activate mania or hypomania. The reported incidence ranged from 0.1% to 2% in premarketing testing of several SSRIs. Patients with bipolar disorder are generally more likely to experience mania from antidepressants. Therapy with SSRIs should be administered cautiously in patients with a history of mania or bipolar disorder. Prior to initiating treatment, it is recommended to adequately screen patients for bipolar disorder, including a family history of suicide, bipolar disorder, and depression.

Antiepileptic drugs (AEDs) have been associated with an increased risk of suicidal thoughts or behavior in patients taking these drugs for any indication. Pooled analyses of 199 placebo-controlled clinical studies involving the use of 11 different AEDs showed that patients receiving AEDs had approximately twice the risk of suicidal thinking or behavior compared to patients receiving placebo. AEDs should be administered cautiously in patients with depression or other psychiatric disorders; phentermine-topiramate should be avoided in patients with history of suicidal attempts or active suicidal ideation. The risk of suicidal thoughts and behavior should be carefully assessed against the risk of untreated illness, bearing in mind that epilepsy and many other conditions for which AEDs are prescribed are themselves associated with morbidity and mortality and an increased risk of suicidal thoughts and behavior. Patients, caregivers, and families should be alert to the emergence or worsening of signs and symptoms of depression, any unusual changes in mood or behavior, or the emergence of suicidal thoughts or behavior. If patients have symptoms of suicidal ideation or behavior, a dosage reduction or treatment discontinuation should be considered.

Reduced plasma bicarbonate levels and, in some instances, elevated plasma chloride levels may result in metabolic acidosis during long-term therapy with carbonic anhydrase inhibitors. Therapy with carbonic anhydrase inhibitors should be administered cautiously in patients with metabolic or hyperchloremic acidosis or with conditions that predispose to acidosis (renal disease, severe respiratory disorders, diarrhea). The measurement of baseline and periodic serum bicarbonate is recommended. If metabolic acidosis develops (it may be corrected by administration of sodium bicarbonate), and persists, a dose reduction or treatment discontinuation should be considered.

A syndrome consisting of acute myopia associated with secondary angle closure glaucoma has been reported in patients receiving topiramate. Symptoms include acute onset of decreased visual acuity and/or ocular pain. It typically occurs within 1 month of treatment initiation and it has been reported in both pediatric and adult patients. Caution is recommended when prescribing topiramate in patients with elevated intraocular pressure regardless of the etiology.

Topiramate is cleared by hemodialysis at a rate that is 4 to 6 times greater than that in a normal individual. To avoid rapid drops in topiramate plasma level during hemodialysis, a supplemental dose may be required. The actual adjustment should consider the duration of dialysis, the clearance rate of the dialysis system being used, and the effective renal clearance of topiramate in the patient being dialyzed.

The use of topiramate increases the risk of kidney stones. The reported incidence was 1.5% during premarketing use, which is about 2 to 4 times that expected in a similar, untreated population. Topiramate is a carbonic anhydrase inhibitor and may promote stone formation by reducing urinary citrate excretion and increasing urinary pH. Therapy with topiramate should be administered cautiously with adequate hydration in patients, especially those with predisposing factors (e.g., history of nephrolithiasis), to minimize the risk of kidney stone formation. The concomitant use of topiramate with any other drug producing metabolic acidosis, or potentially in patients on a ketogenic diet, may create a physiological environment that increases the risk of kidney stone formation and should be avoided. Patients who are dehydrated may be at increased risk for the development of nephrolithiasis and should be encouraged to consume additional amounts of liquid during topiramate therapy.

The use of selective serotonin reuptake inhibitors (SSRIs) has rarely been associated with hyponatremia, sometimes secondary to development of the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). These events have generally been reversible following discontinuation of SSRI therapy and/or medical intervention. SSRI-related hyponatremia may be more common in elderly female patients and those who are volume-depleted or receiving concomitant diuretic therapy. Caution may be warranted when SSRI therapy is administered in these patients and patients with preexisting hyponatremia or SIADH. Serum electrolytes, especially sodium as well as BUN and plasma creatinine, should be monitored regularly.

Treatment with SSRI antidepressants can cause hyponatremia. Caution should be used when treating patients with hyponatremia or at greater risk of hyponatremia such as the elderly, patients taking diuretics or who are volume depleted.

Plasma clearance of topiramate decreased a mean of 26% in patients with moderate to severe liver dysfunction. After a single dose of phentermine 15 mg-topiramate 92 mg, pharmacokinetics of topiramate were not affected in patients with mild (Child-Pugh score 5 to 6) and moderate (Child-Pugh score 7 to 9) liver dysfunction when compared with healthy subjects. Patients with inborn errors of metabolism or reduced hepatic mitochondrial activity may be at increased risk for hyperammonemia with or without encephalopathy. Although not studied, use of topiramate may exacerbate existing defects or unmask deficiencies in susceptible patients.

Selective serotonin reuptake inhibitors (SSRIs) are primarily metabolized by the liver. The plasma concentrations of SSRIs and their metabolites may be increased and the half-lives prolonged in patients with impaired hepatic function. Dosage adjustments may be necessary in accordance with the individual product package labeling.

Selective serotonin reuptake inhibitors (SSRIs), like other antidepressants, may occasionally cause or activate mania or hypomania. The reported incidence ranged from 0.1% to 2% in premarketing testing of several SSRIs. Patients with bipolar disorder are generally more likely to experience mania from antidepressants. Therapy with SSRIs should be administered cautiously in patients with a history of mania or bipolar disorder. Prior to initiating treatment, it is recommended to adequately screen patients for bipolar disorder, including a family history of suicide, bipolar disorder, and depression.

Plasma clearance of topiramate decreased a mean of 26% in patients with moderate to severe liver dysfunction. After a single dose of phentermine 15 mg-topiramate 92 mg, pharmacokinetics of topiramate were not affected in patients with mild (Child-Pugh score 5 to 6) and moderate (Child-Pugh score 7 to 9) liver dysfunction when compared with healthy subjects. Patients with inborn errors of metabolism or reduced hepatic mitochondrial activity may be at increased risk for hyperammonemia with or without encephalopathy. Although not studied, use of topiramate may exacerbate existing defects or unmask deficiencies in susceptible patients.

A syndrome consisting of acute myopia associated with secondary angle closure glaucoma has been reported in patients receiving topiramate. Symptoms include acute onset of decreased visual acuity and/or ocular pain. It typically occurs within 1 month of treatment initiation and it has been reported in both pediatric and adult patients. Caution is recommended when prescribing topiramate in patients with elevated intraocular pressure regardless of the etiology.

The use of topiramate increases the risk of kidney stones. The reported incidence was 1.5% during premarketing use, which is about 2 to 4 times that expected in a similar, untreated population. Topiramate is a carbonic anhydrase inhibitor and may promote stone formation by reducing urinary citrate excretion and increasing urinary pH. Therapy with topiramate should be administered cautiously with adequate hydration in patients, especially those with predisposing factors (e.g., history of nephrolithiasis), to minimize the risk of kidney stone formation. The concomitant use of topiramate with any other drug producing metabolic acidosis, or potentially in patients on a ketogenic diet, may create a physiological environment that increases the risk of kidney stone formation and should be avoided. Patients who are dehydrated may be at increased risk for the development of nephrolithiasis and should be encouraged to consume additional amounts of liquid during topiramate therapy.

Antiepileptic drugs (AEDs) have been associated with an increased risk of suicidal thoughts or behavior in patients taking these drugs for any indication. Pooled analyses of 199 placebo-controlled clinical studies involving the use of 11 different AEDs showed that patients receiving AEDs had approximately twice the risk of suicidal thinking or behavior compared to patients receiving placebo. AEDs should be administered cautiously in patients with depression or other psychiatric disorders; phentermine-topiramate should be avoided in patients with history of suicidal attempts or active suicidal ideation. The risk of suicidal thoughts and behavior should be carefully assessed against the risk of untreated illness, bearing in mind that epilepsy and many other conditions for which AEDs are prescribed are themselves associated with morbidity and mortality and an increased risk of suicidal thoughts and behavior. Patients, caregivers, and families should be alert to the emergence or worsening of signs and symptoms of depression, any unusual changes in mood or behavior, or the emergence of suicidal thoughts or behavior. If patients have symptoms of suicidal ideation or behavior, a dosage reduction or treatment discontinuation should be considered.

Citalopram (racemic) and escitalopram (the more pharmacologically active S-enantiomer) are extensively metabolized and only small amounts are excreted unchanged in the urine. No dosage adjustments are necessary in patients with mild to moderate renal impairment, as the oral clearance of citalopram has been shown to decrease only modestly (17%) in these patients compared to those with normal renal function. There is no information on the pharmacokinetics of citalopram or escitalopram in patients with severe renal impairment (CrCl < 20 mL/min). Therapy with these agents should be administered cautiously in such patients.

Reduced plasma bicarbonate levels and, in some instances, elevated plasma chloride levels may result in metabolic acidosis during long-term therapy with carbonic anhydrase inhibitors. Therapy with carbonic anhydrase inhibitors should be administered cautiously in patients with metabolic or hyperchloremic acidosis or with conditions that predispose to acidosis (renal disease, severe respiratory disorders, diarrhea). The measurement of baseline and periodic serum bicarbonate is recommended. If metabolic acidosis develops (it may be corrected by administration of sodium bicarbonate), and persists, a dose reduction or treatment discontinuation should be considered.

The major route of elimination of carbonic anhydrase inhibitors is through the kidney. These drugs should be administered cautiously in patients with reduced renal function and a dose adjustment might be required depending on the level of impairment.

Selective serotonin reuptake inhibitors (SSRIs) may trigger seizures in approximately 0.2% of patients, and some of them are not recommended in patients with unstable epilepsy. Therapy with SSRIs should be administered cautiously in patients with seizure disorders.

The use of selective serotonin reuptake inhibitors (SSRIs) has rarely been associated with hyponatremia, sometimes secondary to development of the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). These events have generally been reversible following discontinuation of SSRI therapy and/or medical intervention. SSRI-related hyponatremia may be more common in elderly female patients and those who are volume-depleted or receiving concomitant diuretic therapy. Caution may be warranted when SSRI therapy is administered in these patients and patients with preexisting hyponatremia or SIADH. Serum electrolytes, especially sodium as well as BUN and plasma creatinine, should be monitored regularly.

The use of selective serotonin reuptake inhibitors (SSRIs) has been associated with altered platelet function. Petechiae, purpura, ecchymosis, increased bleeding times, epistaxis and gastrointestinal hemorrhage have been reported. Therapy with SSRIs should be administered cautiously in patients with severe active bleeding or a hemorrhagic diathesis.

The use of selective serotonin reuptake inhibitors (SSRIs) has been associated with altered platelet function. Petechiae, purpura, ecchymosis, increased bleeding times, epistaxis and gastrointestinal hemorrhage have been reported. Therapy with SSRIs should be administered cautiously in patients with severe active bleeding or a hemorrhagic diathesis.

The use of selective serotonin reuptake inhibitors (SSRIs) has been associated with altered platelet function. Petechiae, purpura, ecchymosis, increased bleeding times, epistaxis and gastrointestinal hemorrhage have been reported. Therapy with SSRIs should be administered cautiously in patients with severe active bleeding or a hemorrhagic diathesis.

The use of selective serotonin reuptake inhibitors (SSRIs) may occasionally cause significant weight loss, which may be undesirable in patients suffering from anorexia, malnutrition or excessive weight loss. Anorexia may occur in approximately 5% to 10% of patients. Weight change should be monitored during therapy if an SSRI is used in these patients.

The use of selective serotonin reuptake inhibitors (SSRIs) may occasionally cause significant weight loss, which may be undesirable in patients suffering from anorexia, malnutrition or excessive weight loss. Anorexia may occur in approximately 5% to 10% of patients. Weight change should be monitored during therapy if an SSRI is used in these patients.

The use of selective serotonin reuptake inhibitors (SSRIs) may occasionally cause significant weight loss, which may be undesirable in patients suffering from anorexia, malnutrition or excessive weight loss. Anorexia may occur in approximately 5% to 10% of patients. Weight change should be monitored during therapy if an SSRI is used in these patients.